Caroline Martinez, MD
Robert Karp, MD
SUNY Downstate Medical Center
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What does being overweight mean?
14% of children in the US are overweight. Being overweight is more than just having a few extra pounds. It means having too much body fat. This can begin in infancy, then in childhood between 4 and 6 years of age, and again during adolescence. Studies have shown that a child who is overweight between 10 and 13 has an 80 percent chance of becoming an obese adult. In the past 40 years the number of overweight children has tripled.
What are the causes?
Poor food choices, too little activity, and lots of stress. These poor food choices are due to the availability and low cost of fast foods, strong marketing of these foods, increased consumption of highly processed, high calorie foods (including sugary beverages). Sedentary lifestyles are due to lack of exercise and increase in TV and computer time. Stressful life changes, family peer and emotional problems can also be associated with obesity in childhood and adolescence.
What risks are associated with being overweight?
Excessive body weight is associated with the development of diabetes, heart disease, sleep apnea, several different types of cancer (colon, breast, ovarian). Children with obesity are more likely to suffer from poor self esteem and be depressed and anxious.
Being overweight is often a lifelong issue. Once adolescence occurs, old habits of eating and exercising are difficult to change. The best way to manage obesity is with prevention.
It is important for the entire family to be involved. Making healthy choices in eating habits and exercise will benefit the whole family.
A list of “8 Habits of Healthy Kids”*
1. Spend at least 1 hour a day being physically active.
2. Limit use of TV and video games to no more than 1 hour a day.
3. Eat smaller amounts. Bigger is not always better!
4. Eat a total of 5 or more servings of fruits and vegetables a day.
5. Drink or eat 3 low-fat dairy food each day.
6. Eat less fast food – no more than once a week.
7. Drink water instead of soda, “drink” juice. The limit for juice is 6 ounces a day.
8. Snack on healthy foods. Eat less “junk” food and sweets.
Adapted from the New York City Department of Health using a model prepared by the Strang Cancer Prevention Center’s “Healthy Children’s Healthy Futures” program. - with permission. [Numbers 4 and 5 are from the Dietary Approach to Stop Hypertension -DASH program]
How can children that are overweight lose weight?
A pediatrician should evaluate overweight children to make sure there is no medical cause. If there is no medical disorder responsible, weight loss can be achieved by reducing calories, increasing physical activity, and decreasing sedentary time. Your pediatrician will help come up with a comprehensive plan but the child’s motivation comes first. The plan should include reasonable weight loss goals, dietary and physical activity management and changing eating behaviors. Children can become lean by holding weight constant as they grow taller. The family will be involved with every step. Making healthy changes in eating habits and exercise can benefit the whole family while improving weight control for individual kids.
HOW TO PREVENT YOUR CHILD FROM BECOMING OVERWEIGHT AT THE BEGINNING
Nutrition before and during pregnancy
- Good nutrition is key from the very beginning.
- Eat a balanced diet and take B vitamin supplements which contain folate.
- Moderate weight gain is recommended.
- In cases of gestational diabetes, tight glycemic control is important.
Nutrition from birth to six months
- Breast-feeding is best! It benefits the baby and the mom.
In babies, breastfeeding decreases the incidence of infections, allergic diseases and might reduce childhood obesity. For moms, breastfeeding helps promote weight loss, aids in birth control, strengthens bonding and saves money.
Breast milk contains a high amount of many vitamins and nutrients. It does not contain enough Vitamin D. Be sure to ask your doctor about supplementation during breast-feeding. Breast milk provides nutritional requirements until babies start eating solid foods. Water and juice are usually unnecessary during first 6 months. In general fruit juices should be diluted with water and kept to a minimum even when baby is older as juices are filled with sugar that can fill children up and increase risk of cavities.
Moderate weight gain for all birth weights is recommended. Low birth weight babies that catch up in weight too fast increase the risk of obesity. Always check with your doctor about the right amount of weight your baby should gain.
6 Months to 1 Year
Baby is now ready for solids foods (check with your pediatrician first). The usual first food is rice cereal mixed with breast milk or formula. Once the baby is used to cereal, vegetables and fruits can be introduced one at a time at about 2-7 day intervals.
By about 8 months old, most babies are pros at handling cereals and pureed vegetables and fruits. It may be time to step up to some new, coarser textures that require a little chewing. You can purchase "chunky" baby foods, or you can fork-mash, cut up, or grind your family's table food. Make sure to continue to give all new foods a trial run (a few days) to look for any allergic reactions. Variety at this stage is also important. It may take repeated exposures for your baby to accept a particular food. Experience with a wide variety of foods in the first 2 years can lead to acceptance of more foods in later childhood.
Let your child feed himself! Foods to try are boiled carrots, pre-cooked sweet peppers cut in strips and round oat cereals.
By the time the baby is one year old he/she will be eating a variety of foods and sharing many of the family’s meals. This is a great time to evaluate the quality of the foods the family eats. Is the diet rich in fruits and vegetables and low in sugar salt and fat? [We suggest delaying introduction of low fat milk until 2 years of age.] Are bread and grain products whole grain instead of refined starch?
TODDLER YEARS
Positive Role Modeling: Continue positive nutritional start by evaluating the nutritional value of the foods you and your baby eat. Encourage the family to establish regular mealtimes and to eat together whenever possible, and to serve the family's meal to the toddler even if it is sometimes rejected.
Try to limit fats, sugar, sodium, and of sugary beverages like fruit juice. Instead include fruits and vegetables, lean meats and whole grain bread products. The American Medical Association recommends that children younger than 12 months of age get as many as 50 percent of their daily calories from fat for healthy growth and brain development. Children shouldn't be on reduced fat diets before 2 years of age.
Variety: It is a good idea to offer your toddler a variety of healthy foods at this stage Involving toddlers in food preparation (mixing dips for vegetables), introducing new foods in familiar contexts and practicing patience and persistence will often help broaden picky eaters. Give choices and include a variety of textures and colors. This will help create interest. Remember to offer positive reinforcement for healthy choices, avoid criticism.
Physical Activity:
• It is important to spend time together in active play, such as playground and park. Be sure to take walks together everyday.
• Toddler hood is a key time to establish firm limits on television watching per day. Try to limit viewing to 1 hour or less daily. Keeping the television out of plain sight and out of the bedroom. Television often distracts from natural signals of hunger and fullness. Have separate times and spaces for snacking and television watching.
PRESCHOOL
The preschool period is an excellent time to emphasize that a proper diet is part of a healthy lifestyle. Attitudes and habits formed during preschool years are likely to be carried into adulthood.
Basic nutritional needs of children are similar to the nutritional needs of other family members. Amounts needed differ because of age. Offer your child a variety of foods from the basic food groups:
Breads, cereals, rice and pasta
Vegetables
Fruits
Milk, yogurt and cheese
Meats, poultry, fish, dry beans and peas, and eggs.
Portion sizes should be small, i.e. 1 cup of cereal with<1 cup of milk, a sandwich, a cup of rice. Pay close attention to signs that your child is full. Studies have shown that young children naturally regulate their food intake according to how hungry they are but at around age 3-5 they begin to ignore these internal hunger cues and respond to external cues such as portion size.
Continue to watch sugar intake especially sweetened fruit juices as high sugar leads to dental cavities, hyperactivity and obesity. Reduced fat milk is recommended after the age of 2.
Again, try to limit children's TV time and increase physical activity. There is a direct relationship between hours of televisionwatching per day and obesity. TV viewing takes away from important activities such as reading, schoolwork, playing, exercise, family interaction and social development.
Tips for TV Viewing
1. Start by setting limits on how many how many hours (1 or two at the most) your child can watch TV. Pick the time, too, this should not be while studying or during meals.
2. As with food, don’t use TV as a reward or punishment. This will only increase its value to your child.
3. When possible watch TV with your children and discuss what they see. Relate personal and family values to TV show and make sure kids know the distinction between what’s on the TV and real events. Explain that commercials may make people want things that aren’t good for them or that they don’t need.
4. Overall, encourage children to eat healthy foods and only to eat when they're hungry. Don't use food as a reward system. Make good foods fun and try to eat meals together as often as possible.
SCHOOL AGE
Become a nutritional role model if you have not already.
Keep mainly healthy foods around the house: try having a "healthy" shelf in the refrigerator, with fruit, cut-up vegetables, lean meats, and low-fat cheeses that kids can grab themselves.
Buy low-fat or nonfat milk and whole-grain breads. Use whole grain cereals like Cheerios and raisin bran.
Pack nutritious snacks and meals for school and family outings, instead of going to fast-food restaurants or relying on your child to make healthy choices in the school cafeteria.
Help kids resist the temptation of junk food at school snack bars by providing healthy snacks. Many snacks that are advertised as healthy are high in sugar and fat. Try to stay involved in choosing and preparing healthy snacks for your children as they grow. And try not to let your child fall victim to the latest snack gimmick.
Encourage children to be physically active every day, whether it's a pick-up game of soccer or playing in a community sports league. If team sports are not enjoyable to your child, explore other options at school or local YMCA like dance or martial arts. Make sure kids are active at home, too, through everyday activities like walking and or playing in the yard. Even basic household chores like folding laundry, washing the car, and raking leaves burn calories. It is important to support healthy body image, emphasizing strength and health rather than weight and appearance.
TEENS
Much research has been done to identify how teens make food choices. Important factors include: Appeal (taste, appearance, smell), Time, and Convenience (easy to make / no clean-up involved). Of secondary importance: Availability (school lunch and at home), Parental Influence (family meal patterns), Perceived benefits (nutrition / health), Situations (social interaction).
Encourage adolescents to:
• Eat a variety of foods
• Choose a diet with plenty of grain products, vegetables
and fruits
• Choose a diet low in fat, saturated fat, and cholesterol
• Choose a diet moderate in sugars and salt
• Choose a diet that provides enough calcium and iron to
meet their growing body's requirements.
• Keep the mind and body in shape with regular exercise
Teenagers are at risk for eating disorders such as anorexia and bulimia. Signs and symptoms that your child has a potential eating disorder include:
• Not wanting to eat meals with the family
• Frequent, long visits to the bathroom during or just
after meals.
Your teenage child may run water to obscure the sound
of induced vomiting
• Excessive exercise or preoccupation with weight
• Wanting to be alone
AT ANY AGE
If you think your child’s weight could affect him or her physically and psychologically it is best to see a doctor. Try to take a relaxed attitude and emphasize a healthy body from the inside rather than focusing on your child’s appearance.
REFERENCES
Healthy People 2010. http://www.healthypeople.gov/
Kid’s Health. http://www.kidshealth.com/
Tufts University Child and Family WebGuide.
http:// www.cfw.tufts.edu/CDC
http://www.cdc.gov/nccdphp/dnpa/obesity/index.htm
AAP-overweight and obesity site http://www.aap.org/healthtopics/overweight.cfm
Overcoming obesity in America. Time magazine June 7, 2004.
American Academy of Pediatrics Committee on Nutrition. Prevention of pediatric overweight and obesity. Pediatrics. 2003;112:424-430
Brody, Jane E. TV’s Toll on Young Minds and Bodies. The New York Times. August, 3. 2004
Butte, N. The Start Healthy Feeding Guidelines for Infants and Toddlers. The Journal of the American Dietetic Association, 2004: Vol. 104(3), 442-454
Dietz WH. Overweight in childhood and adolescence. N Engl J Med 2004;350:855-857
Guzman, S., et al. Practical Advice for Family Physicians to Help Overweight Patients. American Academy of Family Physicians Monograph. 2003.
Hoppin AG. Assessment and management of childhood and adolescent obesity. Medscape Primary Care; June 25, 2004
Polhamus, B. et al. Overview of the CDC Growth Charts Medscape Primary Care; December 18, 2003
Scudder, L. Evaluating Pediatric Growth and Nutrition: Guidelines for the Primary Care Clinician National Conference for Nurse Practitioners 2001
